SCSEP Pre-Application

The NICOA Senior Community Service Employment Program offers part-time paid work experience training in community agencies for older individuals who have limited incomes. Eligibility is based on age and total family income, and most-in-need characteristics. Those who are veterans, over the age of 65, and documented most-in-need are given preference for selection to be enrolled in SCSEP.

Please complete the following questionnaire and return it to a NICOA SCSEP office. This information will be used to screen your eligibility to apply for enrollment in SCSEP. If you appear to be eligible and there are openings in the NICOA SCSEP, someone on our staff will contact you to complete a full application. When you are contacted to complete a full application, you will be required to provide written documentation of age, total family income, and other characteristics.

THANK YOU for providing accurate information. Completion of this questionnaire does not mean that you are eligible or selected for SCSEP enrollment. For further information and submission of this pre-application, contact your local NICOA SCSEP office. All information will be kept confidential.

SCSEP Pre-Application Questionnaire

1) Name

FirstLast

2) Phone

3) Address

Street AddressAddress Line 2CityStateZIP Code

County

4) Do you have an email address?

5) Date of Birth

MM

DD

YYYY

Current Age

6) Are you or your spouse a Veteran?

Yes

No

7) Family Size: How many persons are in your household (including yourself)?

Please enter a number greater than or equal to 1.

Marital Status

Married

Single

8) What is your estimated total annual family income?

9) Are you disabled?

Yes

No

10) Do you receive any payments from public assistance (SSI, other) or disability income (SSDI)?

Yes

No

11) Do you live in a rural area?

Yes

No

12) Is your ability to speak or write in English limited?

Yes

No

13) Are you currently homeless or at risk of homelessness (late in rent or mortgage payments)?

Yes

No

14) Have you completed high school or obtained a GED certificate?

Yes

No

15) How long have you been looking for employment

16) Have you registered and failed to find employment through a One-Stop Career Center?

Yes

No

17) How did you hear about the NICOA SCSEP training program?

Signature

Please type in your full name to confirm the information above is true and correct to the best of your knowledge.